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1.
Background Early postoperative hemorrhage is an infrequent complication of both laparoscopic and open Roux-en-Y gastric bypass (RYGBP).
The objective of our study is to review the incidence and management of this complication and identify contributing clinical
and technical risk factors.
Methods Over a 3-year period, 1,025 patients underwent RYGBP at our institution. The medical records of patients who required postoperative
blood transfusions were reviewed for clinical presentation, diagnostic evaluation and management. These patients were matched
for surgical approach (open vs. laparoscopic) in a 1:3 ratio and compared to a random group of patients who underwent RYGBP
during the same time period.
Results Thirty-three patients (3.2%) were diagnosed with postoperative hemorrhage, 17 (51.5%) of which were intraluminal. The incidence
of hemorrhage was higher in the laparoscopic group (5.1% vs. 2.4%, p = 0.02). Comparing bleeders to nonbleeders, the average BMI, gender distribution, gastro-jejunostomy anastomotic technique
(stapled vs. hand sewn) and the postoperative administration of ketorolac were not significantly different. The bleeding group
was older (47.5 vs. 42.8, p = 0.02), had a longer hospital stay (4.9 vs. 3 days, p = 0.0001) and was more likely to have received low molecular weight heparin (LMWH) preoperatively (p = 0.03). Hemorrhage occurred earlier (13.8 vs. 25.9 h, p = 0.039) and was more severe (4.1 vs. 2.3 transfused blood units, p = 0.007) in the patients who required surgical reexploration (n = 9).
Conclusions A laparoscopic approach and the preoperative administration of LMWH may increase the incidence of early hemorrhage after RYGBP.
This complication frequently requires surgical reexploration and significantly prolongs the hospital stay.
Oral presentation and 1st prize winner, Bariatric surgery competition, CTACS meeting, November 2006.
Poster presentation at the New England Surgical Society meeting, September 2007. 相似文献
2.
Swee H. Teh Daniel Tseng Brett C. Sheppard 《Journal of gastrointestinal surgery》2007,11(9):1120-1125
The aim of the study is to provide comparisons of the perioperative outcomes between open and laparoscopic distal pancreatic
resection (DPR) for benign pancreatic disease. From 2002 and 2005, there were 28 patients (16 open, 12 laparoscopic) with
a mean age of 52 who had presumptive diagnoses of benign pancreatic lesions. Pathology was neuroendocrine tumor (nine and
five), mucinous cystic neoplasm (three and three), symptomatic pancreatic pseudocyst (two and two), and others (two and two).
The mean operative time was 278 vs 212 min (p = 0.05), the estimated blood lost was 609 vs 193 ml (p = 0.01), and the success rate of preoperative intent for splenic preservation was 17 vs 62% (p = 0.08) in the open and laparoscopic groups, respectively. Two patients (16%) were converted to an open procedure. There
was no perioperative mortality. The mean hospital stay and total perioperative morbidity were 10.6 vs 6.2 days (p = 0.001) and nine vs two events (p = 0.03) in the open and laparoscopic groups, respectively. Ten of 12 patients (83%) with laparoscopic DPR had adequate oral
intake within 72 h post operatively in contrast to 2 of 16 (12.5%) patients in the open DPR group (p = 0.0001). Laparoscopic DPR is technically feasible, safe, and associated with less perioperative morbidity and a shorter
hospital stay than open DPR. In centers with the appropriate expertise, laparoscopic DPR should be considered the procedure
of choice for putative benign lesions of the pancreatic body and tail.
Presented at the AHPBA Spring Meeting, Miami Beach, FL March 9–12, 2006 (oral presentation) 相似文献
3.
Background The metabolic syndrome is associated with significant cardiovascular morbidity and mortality. We assessed the in-hospital
outcomes of bariatric surgery in morbidly obese patients with the metabolic syndrome in comparison to a control group without
the metabolic syndrome.
Methods Using ICD-9-CM diagnosis and procedure codes, clinical data for 20,242 patients with and without the metabolic syndrome who
underwent bariatric surgery over a 5-year period were obtained from the University HealthSystem Consortium database.
Results The prevalence of the metabolic syndrome among bariatric surgery patients was 27.4%. Patients with the metabolic syndrome
presented significantly higher overall morbidity as compared to morbidly obese patients without the metabolic syndrome (8.6%
vs. 5.8%; p < 0.01), and similar mortality (0.04% vs. 0.01%; p = 0.2) after bariatric surgery. Hispanics with the metabolic syndrome had the highest morbidity rates, and men had the uppermost
mortality. In-hospital bariatric surgery outcomes were significantly improved among patients who underwent laparoscopic adjustable
gastric banding.
Conclusions The data suggest that the presence of the metabolic syndrome affects inter-ethnic and gender-specific short-term outcomes
after bariatric surgery. 相似文献
4.
Urs Zingg Alexander McQuinn Dennis DiValentino Steven Kinsey-Trotman Philip Game David Watson 《Obesity surgery》2010,20(12):1627-1632
With the increase in bariatric procedures performed, revisional surgery is now required more frequently. Roux-en-Y gastric
bypass (RYGB) is considered to be the gold standard revision procedure. However, data comparing revisional vs. primary RYGB
is scarce, and no study has compared non-resectional primary and revisional RYGB in a matched control setting. Analysis of
61 revisional RYGB that were matched one to one with 61 primary RYGB was done. Matching criteria were preoperative body mass
index, age, gender, comorbidities and choice of technique (laparoscopic vs. open). After matching, the groups did not differ
significantly. Previous bariatric procedures were 13 gastric bands, 36 vertical banded gastroplasties, 10 RYGB and two sleeve
gastrectomies. The indication for revisional surgery was insufficient weight loss in 55 and reflux in 6. Intraoperative and
surgical morbidity was not different, but medical morbidity was significantly higher in revisional procedures (9.8% vs. 0%,
p = 0.031). Patients undergoing revisional RYGB lost less weight in the first two postoperative years compared with patients
with primary RYGB (1 month, 14.9% vs. 29.7%, p = 0.004; 3 months, 27.4% vs. 51.9%, p = 0.002; 6 months, 39.4 vs. 70.4%, p < 0.001; 12 months, 58.5% vs. 85.9%, p < 0.001; 24 months, 60.7% vs. 90.0%, p = 0.003). Although revisional RYGB is safe and effective, excess weight loss after revisional RYGB is significantly less
than following primary RYGB surgery. Weight loss plateaus after 12 months follow-up. 相似文献
5.
Alessandro Fichera Mark T. Silvestri Roger D. Hurst Michele A. Rubin Fabrizio Michelassi 《Journal of gastrointestinal surgery》2009,13(3):526-532
Purpose Long-term results after laparoscopic ileal pouch anal anastomosis (IPAA) have not been thoroughly evaluated. Our study prospectively
compares short- and long-term outcomes of laparoscopic and open IPAA.
Methods Between October 2002 and November 2007, 73 laparoscopic and 106 open IPAA patients were enrolled. Patient- and disease-specific
characteristics and short- and long-term outcomes were prospectively collected.
Results There were no differences in demographics, treatment, indication, duration of surgery, and diversion between groups. Laparoscopic
patients had faster return of flatus (p = 0.008), faster assumption of a liquid diet (p < 0.001), and less blood loss (p = 0.026). While complications were similar, the incidence of incisional hernias was lower in the laparoscopic group (p = 0.011). Mean follow-up was 24.8 months. Average number of bowel movements was 6.8 ± 2.8/day for laparoscopy and 6.3 ± 1.7
for open (p = 0.058). Overall, 68.4% of patients were fully continent at 1 year, up to 83.7% long term without differences between groups.
Other indicators of defecatory function and quality of life remain similar overtime.
Conclusions Laparoscopic IPAA confers excellent functional results. Most patients are fully continent and have an average of six bowel
movements/day. When present, minor incontinence improves over time. Laparoscopy mirrors the results of open IPAA and is a
valuable alternative to open surgery.
This study was funded in part by the University of Chicago Cancer Research Foundation (UCCRF) Auxiliary Board Research Support
Grant (A.F.).
Presented at the American Society of Colon and Rectal Surgeons Tripartite Meeting. Boston. June 9, 2008. 相似文献
6.
Giuseppe S. Sica Edoardo Iaculli Domenico Benavoli Livia Biancone Emma Calabrese Sara Onali Achille L Gaspari 《Journal of gastrointestinal surgery》2008,12(6):1094-1102
Possible relations between surgical approaches, frequency, and severity of Crohn’s disease recurrence after ileo-colonic resection
is unknown. We aimed to assess perioperative outcomes and postsurgical complications of laparoscopic versus standard open
surgery and to detect differences between the two groups in endoscopical recurrence and patients’ satisfaction. Twenty-eight
consecutive patients undergoing elective ileo-colonic resection by either laparoscopic approach (n = 15) or conventional open surgery (n = 13) were prospectively enrolled. No mortality or major intraoperative complications were observed in both groups. Significant
differences between groups were the median operating time found shorter in the open group than in the laparoscopic group (p = 0.003), the higher dosage of pain killers needed in the open group (p = 0.05), the passage of flatus and\or stool after surgery found faster in group A (p = 0.004) and the shorter recovery period in the laparoscopic group (p = 0.007). Colonoscopy was performed in 27 patients. The frequency and pattern of recurrence did not differ between the two
groups (p = 0.63). Patients’ satisfaction was significantly in favor of laparoscopy. Present findings support the feasibility and advantages
in the short-term of laparoscopic ileo-colonic resection in patients with Crohn’s disease. No differences were observed in
terms of frequency, time of onset, and severity of recurrence in a 1-year follow-up. 相似文献
7.
Effect of Location and Speed of Diagnosis on Anastomotic Leak Outcomes in 3828 Gastric Bypass Cases 总被引:1,自引:0,他引:1
Sukhyung Lee Brennan Carmody Luke Wolfe Eric DeMaria John M. Kellum Harvey Sugerman James W. Maher 《Journal of gastrointestinal surgery》2007,11(6):708-713
Introduction Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between
the leak site, time from surgery to detection, and outcome.
Methods Retrospective review of 3,828 gastric bypass procedures.
Results Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric
bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828).
Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the
open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group
(3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did
not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy
leak group (4 vs 2 days, p = 0.037).
Discussion Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with
normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings
should not delay therapy if clinical signs suggest a leak.
This paper was presented at The Society for Surgery of the Alimentary Tract, 47th Annual Meeting at Digestive Disease Week
2006, May 20–24, 2006, Los Angeles, California. 相似文献
8.
Hiroko Kunitake Richard Hodin Paul C. Shellito Bruce E. Sands Joshua Korzenik Liliana Bordeianou 《Journal of gastrointestinal surgery》2008,12(10):1730-1737
Purpose The impact of infliximab (IFX) on postoperative complications in surgical patients with Crohn’s disease (CD) and ulcerative
colitis (UC) is unclear. We examined a large patient cohort to clarify whether a relationship exists between IFX and postoperative
complications.
Methods A total of 413 consecutive patients—188 (45.5%) with suspected CD, 156 (37.8%) with UC, and 69 (16.7%) with indeterminate
colitis—underwent abdominal surgery at the Massachusetts General Hospital between January 1993 and June 2007. One hundred
one (24.5%) had received preoperative IFX ≤ 12 weeks before surgery. These patients were compared to those who did not receive
IFX with respect to demographics, comorbidities, presence of preoperative infections, steroid use, and nutritional status.
We then compared the cumulative rate of complications for each group, which included deaths, anastomotic leak, infection,
thrombotic complications, prolonged ileus/small bowel obstruction, cardiac, and hepatorenal complications. Potential risk
factors for infectious complications including preexisting infection, pathological diagnosis, and steroid or IFX exposure
were further evaluated using logistic regression analysis.
Results Patients were similar with respect to gender (IFX = 40.6% men vs. non-IFX = 51.9%, p = 0.06), age (36.1 years vs.37.8, p = 0.43), Charlson Comorbidity Index (5.3 vs. 5.7, p = 0.25), concomitant steroids (75.3% vs. 76.9%, p = 0.79), preoperative albumin level (3.3 vs. 3.2, p = 0.36), and rate of emergent surgery (3.0% vs. 3.5%, p = 1.00). IFX patients had higher rates of CD (56.4% vs. 41.9%, p = 0.02), concomitant azathioprine/6-mercaptopurine use (34.6% vs. 16.6%, p < 0.0001), and lower rates of intra-abdominal abscess (3.9% vs. 11%, p < 0.05). After surgery, the two groups had similar rates of death (2% vs. 0.3% p = 0.09), anastomotic leak (3.0% vs. 2.9%, p = 0.97), cumulative infections (5.97% vs. 10.1%, p = 1), thrombotic complications (3.6% vs. 3.0%, p = 0.06), prolonged ileus/small bowel obstructions (3.9 vs. 2.8, p = 0.59), cardiac complications (1% vs. 0.6%, p = 0.42), and hepatic or renal complications (1.0 vs. 0.6% p = 0.72). A logistic regression model was then created to assess the impact of IFX, as well as other potential risk factors,
on the rates of cumulative postoperative infections. We found that steroids (odds ratio [OR] = 1.2, p = 0.74), IFX (OR 2.5, p = 0.14), preoperative diagnosis of CD (OR = 0.7, p = 0.63) or UC (OR = 0.6, p = 0.48), and preoperative infection (OR = 1.2, p = 0.76) did not affect rates of clinically important postoperative infections.
Conclusions Preoperative IFX was not associated with an increased rate of cumulative postoperative complications.
Dr. Sands has received research grants and honoraria for lecturing and consulting from Centocor. 相似文献
9.
Toshihiko Shinohara Tetsuji Fujita Takeyuki Misawa Taro Sakamoto Kazuhiko Yoshida Hideyuki Kashiwagi Katsuhiko Yanaga 《Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie》2009,394(3):557-562
Background The purpose of this study was to evaluate the long-lasting influence of laparoscopic training during residency course on outcomes
of laparoscopic cholecystectomy (LC).
Materials and methods We compared outcomes of LC in patients treated by surgeons who have learned LC by the traditional surgical residency program
(traditional group; n = 15) with those of LC operated on by surgeons who received additional intensive laboratory training in their residency [Jikei
Surgical Skill Training Program (JSTP) group; n = 9].
Results Among the 503 patients subjected to LC, 302 (60.0%) cases were performed by surgeons in the traditional group and 201 (40.0%)
cases in the JSTP group. The patient characteristics, operative outcome variables, and the pathological findings of the gallbladder
were comparable in the two groups. Despite no difference in the above factors, conversion rates were significantly higher
in the traditional group compared with the JSTP group (10.6% vs 5.0%; p = 0.026). In multivariate analysis, training background was an independent risk factor for conversion to open surgery (odds
ratio, 2.79; 95% confidence interval, 1.25–6.24).
Conclusions To ensure competence for laparoscopic skills, we propose that such training program should be integrated into the curriculum
of the general surgery residency. 相似文献
10.
Subhashini M. Ayloo Nicolas C. Buchs Pietro Addeo Francesco M. Bianco Pier C. Giulianotti 《Obesity surgery》2011,21(7):815-819
In bariatric surgery, laparoscopic adjustable gastric banding (LAGB) has proven effective in reducing weight and improving
obesity-associated comorbidities. Recently, however, laparoendoscopic single-site (LESS) surgery has been proposed to minimize
the invasiveness of laparoscopic surgery. The aim of this study is to compare the operative cost and peri-operative outcomes
of these two approaches. We undertook a retrospective review of a prospectively maintained database of patients undergoing
either LAGB or LESS between March 2006 and October 2009. The outcomes and cost of 25 LESS gastric bandings were compared to
121 standard LAGB. Costs included operative time, consumables, and laparoscopic tower depreciation. Both groups had similar
patient demographics, body mass index, and comorbidities; with the exception of age (37 year for single site vs. 44 years
for standard; P = 0.002). There were no statistical differences for operative time (78 vs. 76 min, P = 0.69), blood loss (8.4 vs. 9 ml, P = 0.76), pain score (0.81 vs. 0.84 at 1 week, P = 0.95) or complication rates (12% vs. 14%, P = 1). Length of stay was shorter for the LESS group (0.5 day vs. 1.5 days, P = 0.02). The mean operative cost for the LESS banding was 20,502/case vs.20,502/case vs. 20,346/case for the standard LAGB, with no statistically
significant difference between the approaches (P = 0.73). Operative costs and peri-operative outcomes of LESS gastric banding are comparable with those of the standard LAGB
procedure. As a result, single-site surgery can be proposed as a valid alternative to the standard procedure with cosmetic
advantage and comparable complication rate. 相似文献
11.
Andre da Luz Moreira Luca Stocchi Feza H. Remzi Daniel Geisler Jeffery Hammel Victor W. Fazio 《Journal of gastrointestinal surgery》2007,11(11):1529-1533
Introduction The purpose of this study was to compare short and long-term outcomes of laparoscopic colectomy with open colectomy in patients
with Crohn’s disease confined to the colon.
Materials and Methods We reviewed all patients undergoing laparoscopic colectomy for Crohn’s disease at our institution between 1994 and 2005. Laparoscopic
colectomies were matched to open colectomies by patient age, gender, American Society of Anesthesiologists score, type, and
year of surgery. We excluded patients with concomitant small bowel disease.
Results Twenty-seven laparoscopic cases were matched with 27 open cases. There were seven conversions (26%). There was no mortality.
Median operative times were significantly longer after laparoscopic colectomy (240 vs 150 min, P < 0.01), and estimated blood loss was comparable (325 vs 350 ml, P = 0.4). Postoperative complications were similar. Laparoscopic colectomies had shorter median length of stay (5 vs 6 days,
P = 0.07) and median time to first bowel movement (3 vs 4 days, P = 0.4). When overall length of stay included 30-day readmissions, the difference in favor of laparoscopy became statistically
significant (P = 0.02). Recurrent disease requiring surgery was decreased after laparoscopy, although median follow-up was significantly
shorter.
Conclusion Laparoscopic colectomy is a safe and acceptable option for patients with Crohn’s colitis. Longer follow-up is needed to accurately
establish recurrence rates. 相似文献
12.
Kelly Lesperance Matthew J. Martin Ryan Lehmann Lionel Brounts Scott R. Steele 《Journal of gastrointestinal surgery》2009,13(7):1251-1259
Purpose The laparoscopic approach to Crohn’s disease has demonstrated benefits in several small series. We sought to examine its use
and outcomes on a national level.
Methods All admissions with a diagnosis of Crohn’s disease requiring bowel resection were selected from the 2000–2004 Nationwide Inpatient
Sample. Regression analyses were used to compare outcome measures and identify independent predictors of undergoing laparoscopy.
Results Of 396,911 patients admitted for Crohn’s disease, 49,609 (12%) required surgical treatment. They were predominately Caucasian
(64%), female (54%), and with ileocolic disease (72%). Most had private insurance (71%) and had surgery in urban hospitals
(91%). Laparoscopic resection was performed in 2,826 cases (6%) and was associated with lower complications (8% vs. 16%),
shorter length of stay (6 vs. 9 days), lower charges ($27,575 vs. $38,713), and mortality (0.2% vs. 0.9%, all P < 0.01). Open surgery was used more often for fistulas (8% vs. 1%) and when ostomies were required (12% vs. 7%). Independent
predictors of laparoscopic resection were age <35 [odds ratio (OR) = 2.4], female gender (OR = 1.4), admission to a teaching
hospital (OR = 1.2), ileocecal location (OR = 1.5), and lower disease stage (OR = 1.1, all P < 0.05). Ethnic category, insurance status, and type of admission (elective vs. non-elective) were not associated with operative
method (P > 0.05).
Conclusions A variety of patient- and system-related factors influence the utilization of laparoscopy in Crohn’s disease. Laparoscopic
resection is associated with excellent short-term outcomes compared to open surgery.
“The views expressed in the article (book, speech, etc.) are those of the author(s) and do not reflect the official policy
of the Department of the Army, the Department of Defense or the US Government.”
“The investigators have adhered to the policies for protection of human subjects as prescribed in 45 CFR 46.” 相似文献
13.
White B Jeansonne LO Cook M Chavarriaga LF Goldenberg EA Davis SS Smith CD Khaitan L Lin E 《Obesity surgery》2009,19(6):783-787
Background Obese patients with gastroesophageal reflux disease (GERD) refractory to medical therapy are a challenging patient population
as obesity is a preoperative predictor of failure after antireflux surgery. We therefore sought to evaluate outcomes using
one of two commercially available endoluminal therapies in this population.
Methods Consecutive obese patients (body mass index (BMI) > 30) with GERD (DeMeester >14.5) undergoing either Plicator (NDO) or Stretta
(Curon) were identified in our single-institution prospective database. Outcomes assessed were: (1) failure rate (absolutely
no symptomatic improvement after procedure and/or need for subsequent antireflux surgery), (2) postoperative vs. preoperative
symptom (heartburn, chest pain, regurgitation, dysphagia, cough, hoarseness, and asthma) scores, and (3) proton-pump inhibitor
(PPI) medication use.
Results Twenty-two patients each underwent an endoluminal therapy (ten Plicator patients and 12 Stretta patients) with mean follow-up
of 1.5 years. There were no treatment-associated complications. Mean BMI was not different between Plicator and Stretta groups
(39.6 vs. 38.6, respectively, p = 0.33). The failure rate for the entire cohort was 28% (10% Plicator vs. 42% Stretta, p = 0.11). The proportion of patients reporting moderate/severe symptoms postop was significantly less than preop: chest pain
9% vs. 13% (p = 0.04), cough 22% vs. 36% preop (p = 0.025), voice changes 9% vs. 36% preop (p = 0.012), and dysphagia 9% vs. 32% preop (p = 0.04). The proportion of patients on PPI medications postop was also less than preop (45% vs. 81%, p = 0.1)
Conclusion Endoluminal treatment can provide a safe means of improving GERD symptoms for some obese patients, though many will continue
to require medication therapy also. Further work aimed at understanding optimal candidates for endoluminal therapy in this
patient population is warranted. 相似文献
14.
15.
Hip fracture, a moderate musculoskeletal trauma, is associated with a high postoperative mortality. Most patients are elderly,
with comorbid conditions and often with heart disease. The objective of this study was to find out if clinical parameters
and analyses of specific muscle enzymes could predict three month postoperative mortality. A total of 302 patients above 75 years
of age with hip fracture were consecutively enrolled. Baseline information on age, sex and comorbidity assessed with the American
Society of Anesthesiologists (ASA) score was obtained before surgery. Creatine kinase (CK), myocardium-specific creatine kinase
(CK-MB) and troponin T (TnT) were analysed from venous blood, collected the day before surgery (−1) and postoperatively, within
24 hours (0) and on days one (+1) and four (+4). The overall three month mortality was 19.5%. Multivariate analyses showed
that age, male sex and comorbidity (ASA) correlated with mortality (p = 0.027, p = 0.002, p < 0.001, respectively). Surgery induced a two- to threefold increase of CK and CK-MB but without any correlation with mortality.
However, high TnT levels >0.04 μg/l correlated significantly with death (days −1, +1 and +4, p = 0.003, p = 0.005 and p = 0.003, respectively). Multivariate analyses, adjusted for age, sex and ASA category, confirmed this correlation (day +4,
p = 0.008). Thus, in elderly patients with comorbidities undergoing hip fracture surgery information on sex, age, ASA category
and postoperative laboratory analyses on TnT provide the clinicians with useful information on patients at risk of fatal outcome. 相似文献
16.
Bernd M. Muehling Gisela Halter Gunter Lang Hubert Schelzig Peter Steffen Florian Wagner Rainer Meierhenrich Ludger Sunder-Plassmann Karl-Heinz Orend 《Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie》2008,393(3):281-287
Background and aims Fast-track programs have been introduced in many surgical fields to minimize postoperative morbidity and mortality. Morbidity
after elective open infrarenal aneurysm repair is as high as 30%; mortality ranges up to 10%. In terms of open infrarenal
aneurysm repair, no randomized controlled trials exist to introduce and evaluate such patient care programs.
Materials and methods This study involved prospective randomization of 82 patients in a “traditional” and a “fast-track” treatment arm. Main differences
consisted in preoperative bowel washout (none vs. 3 l cleaning solution) and analgesia (patient controlled analgesia vs. patient
controlled epidural analgesia). Study endpoints were morbidity and mortality, need for postoperative mechanical ventilation,
and length of stay (LOS) on intensive care unit (ICU).
Results The need for assisted postoperative ventilation was significantly higher in the traditional group (33.3% vs. 5.4%; p = 0.011). Median LOS on ICU was shorter in the fast-track group, 41 vs. 20 h. The rate of postoperative medical complications
was significantly lower in the fast-track group, 16.2% vs. 35.7% (p = 0.045).
Conclusion We introduced and evaluated an optimized patient care program for patients undergoing open infrarenal aortic aneurysm repair
which showed a significant advantage for “fast-track” patients in terms of postoperative morbidity.
German Society of Surgery, Surgical Forum 2008, Best of Abstracts. 相似文献
17.
Background Obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators
including C-reactive protein (CRP) and white blood cell count (WBC). Recent studies have shown elevated CRP or WBC is a significant
risk factor for cardiac events and stroke but the clinical significance of CRP and WBC has not been clearly studied in morbidly
obese patients. This study is aimed at the clinical significance of WBC and CRP in morbidly obese patients and the change
after bariatric surgery.
Methods The study was a prospectively controlled clinical study. From December 1, 2001 to January 31, 2006, of 640 (442 females and
198 males) consecutive morbid obese patients enrolled in a surgically supervised weight loss program with at least 1 year’s
follow-up were examined.
Results Of the patients, 476 (74.4%) had elevated CRP and 100 (15.6%) had elevated WBC at preoperative study. CRP and WBC were significantly
related and both increased with increasing body mass index (BMI). CRP is also increased with increasing waist, glucose level,
hemoglobin, albumin, Ca, insulin, C-peptide, and metabolic syndrome while WBC is increased with metabolic syndrome but decreased
with increasing age. Multivariate analysis confirmed fasting glucose level and hemoglobin are independent predictors of the
elevation of CRP while age is the only independent predictor for elevated WBC. Both WBC and CRP levels decreased rapidly after
obesity surgery. These improvements resulted in a 69.8% reduction of CRP and 26.4% reduction of WBC 1 year after surgery.
Although individuals who underwent laparoscopic gastric bypass lost significantly more weight (36.8 ± 11.7 kg vs. 17.3 ± 10.8 kg;
p = 0.000) and achieved a lower BMI (27.8 ± 4.6 vs. 35.0 ± 5.5; p = 0.000) than individuals who underwent laparoscopic gastric banding, there was no difference in the resolution of elevated
CRP 1 year after surgery (95.9% vs. 84.5%; p = 0.169) and WBC (99.4% vs. 98.3%; p = 0.323).
Conclusions Both baseline WBC and CRP are elevated in morbid obese patients but CRP has a better clinical significance. Significant weight
reduction 1 year after surgery markedly reduced CRP and WBC with a resolution rate of 93.9% and 98.2% separately. Obesity
surgery performed by laparoscopic surgery is recommended for obese patients with elevated CRP or WBC. 相似文献
18.
A comparison of laparoscopic and abdominal sacral colpopexy: objective outcome and perioperative differences 总被引:2,自引:1,他引:1
Jennifer L. Klauschie Brent A. Suozzi Maureen M. O’Brien Andrew W. McBride 《International urogynecology journal》2009,20(3):273-279
The purpose of this study was to compare anatomic and perioperative outcomes following laparoscopic sacral colpopexy (LSC)
and abdominal sacral colpopexy (ASC). The hypothesis is that the laparoscopic technique has similar anatomic outcomes as compared
with the open technique. A retrospective comparative chart review was conducted consisting of 43 patients who underwent laparoscopic
sacral colpopexy and 41 patients who underwent abdominal sacral colpopexy. Demographics were comparable between groups except
mean follow-up time (LSC = 7.4 months, ASC = 10.6 months). Mean improvement at the apex was similar between the two groups.
Hospital stay in hours was shorter for the LSC group (mean/median = 35.4/30.9) than the ASC group (mean/median = 63.3/54.1,
p < 0.001). Mean operative time was similar (LSC = 183, ASC = 168 min, p = NS) and complication rates were comparable between the groups. Patients undergoing laparoscopic and abdominal sacral colpopexy
have comparable anatomical outcomes and operative times. Laparoscopy affords a shorter hospital stay. 相似文献
19.
Scott R. Steele Tommy A. Brown Robert M. Rush Matthew J. Martin 《Journal of gastrointestinal surgery》2008,12(3):583-591
Purpose Laparoscopic colectomy has only recently become an accepted technique for the treatment of colon cancer. We sought to analyze
factors that affect the type of resection performed and associated outcomes from a large nationwide database.
Methods All admissions with a primary diagnosis of colon cancer undergoing elective resection were selected from the 2003 and 2004
Nationwide Inpatient Samples. Multiple linear and logistic regression analyses were used to compare outcome measures and identify
independent predictors of a laparoscopic approach.
Results We identified 98,923 admissions (mean age 69.2 years). They were predominately Caucasian (81%), had localized disease (63%),
had private insurance (56%), and had surgery performed in urban hospitals (87%). Laparoscopic resection was performed in 3,296
cases (3.3%) and was associated with a lower complication rate (18% vs 22%), shorter length of stay (6 vs 7.6 days), decreased
need for skilled aftercare (5% vs 11%), and lower mortality (0.6% vs 1.4%, all P < 0.01). There was no significant difference in the total hospital charges between the groups ($34,685 vs $34,178, P = 0.19). Independent predictors of undergoing laparoscopic resection were age < 70 (odds ratio [OR] = 1.2, P < 0.01), national region (Midwest OR = 1.9, West OR = 2.0, P < 0.01), and lower disease stage (OR = 2.5, P < 0.01). Ethnic category and insurance status showed no significant association with operative method (P > 0.05).
Conclusions Laparoscopy for colon cancer is associated with improved outcomes in unadjusted analysis and similar charges compared to open
resection. We found no influence of race or payer status on the utilization of a laparoscopic approach. 相似文献
20.
Adhesions are Common and Costly after Open Pouch Surgery 总被引:1,自引:1,他引:0
Pierpaolo Sileri Roberto Sthory Enda McVeigh Tim Child Chris Cunningham Neil J. Mortensen Ian Lindsey 《Journal of gastrointestinal surgery》2008,12(7):1239-1245
Purpose Open ileal pouch surgery leads to high rates of adhesive small-bowel obstruction (SBO). A laparoscopic approach may reduce
these complications. We aimed to review the incidence of adhesive SBO-related complications after open pouch surgery and to
model the potential financial impact of a laparoscopic approach purely as an adhesion prevention strategy.
Materials and Methods We reviewed cases of open ileal pouch patients kept on a database and examined annually. Case notes were studied for episodes
of adhesive SBO requiring admission or reoperation. Similar parameters were studied in a small series undergoing laparoscopic
pouch surgery. The financial burden of the open access complications was estimated and potential financial impact of a laparoscopic
approach modeled.
Results Two hundred seventy-six patients were followed up after open surgery (median, 6.3; range, 0.2–20.1 years). There were 76 (28%)
readmissions (median length of stay, 7.4 days) in 53 patients (19%) and 28 (10%) reoperations (43% within 1 year). Laparoscopic
patients required less adhesiolysis at second-stage surgery (0% vs 36%, p < 0.0001) and had less SBO episodes within 12 months of surgery (0% vs 14%, p < 0.0001) than open patients. Modeling a laparoscopic approach cost $1,450 and saved $3,282, thus netting $1,832 per pouch
constructed.
Conclusion Open ileal pouch surgery results in significant cumulative long-term access-related complications, particularly adhesions.
These impose a large medical burden on patients and financial burden on health-care systems, all of which may be recouped
by a laparoscopic approach, despite higher theater costs. 相似文献